Undergraduate radiology teaching in a UK medical school: a systematic evaluation of current practice.

AIM: To use the Royal College of Radiologists' Undergraduate Radiology Curriculum (RCR URC) as an innovative tool to review undergraduate radiology teaching and ensure it is comprehensive and balanced. MATERIALS AND METHODS: Quantitative and qualitative methods were used to audit and review radiology teaching for students in years 1-3. All radiological teaching on the course was mapped against the RCR URC learning outcomes. An online survey of students in year 3 (n=138) was conducted using Likert (1-5), multiple choice, and free-text questions. RESULTS: There were 954 instances of radiology teaching, with 70% occurring during lectures. Radiology teaching was mapped to 81 of the 96 RCR URC learning outcomes (84.4%). Forty-seven of 138 students responded to the survey. They expressed confidence in understanding what basic imaging entails (x=4.23) and the risks associated with various imaging techniques (x=4.34). They were also confident in chest radiograph interpretation (x=3.62), but were less confident understanding abdominal radiographs (x=2.87). In free-text comments, students requested more tutorial-type teaching and ultrasound instruction. CONCLUSION: The RCR URC is an effective tool for auditing undergraduate radiology teaching, and other medical schools may, therefore, benefit from using this method. This evaluation process incorporating audit and feedback has identified areas for curriculum development. These include incorporating ultrasound into teaching sessions, delivering more small-group teaching, and introducing clinical placements in radiology departments.

Beating the Odds: Successful Establishment of a Phase II/III Clinical Research Trial in Resource-Poor Liberia during the Largest-Ever Ebola Outbreak.

It has been argued that a country such as Liberia, not fully recovered from the devastation of decades of civil unrest, lacked the appropriate ethical and regulatory framework, basic human and health care services, and infrastructure to carry out clinical trials according to international standards of quality during a public health emergency. However, as Liberia, Sierra Leone, and Guinea were being ravaged by the largest and most devastating Ebola Virus Disease (EVD) outbreak ever recorded, the topic of conducting clinical trials of experimental vaccine and treatment candidates in these resource-poor countries generated the keen interest and concern of scientists, researchers, physicians, bioethicists, philanthropists, and even politicians. Decisive action on behalf of the Liberian government, and a timely positive and supportive response from the United States (U.S.) government, led to the formation of PREVAIL (Partnership for Research on Ebola Vaccines in Liberia) - a clinical research partnership between the two governments. Within a span of 12 weeks, this partnership accomplished the unimaginable: the successful initiation of a Phase II/III vaccine clinical trial for EVD in Liberia. This paper will discuss the dynamics of the research collaboration, barriers encountered, breakthroughs realized, key elements of success, and lessons learned in the process.

Finding the fifth intercostal space for chest drain insertion: guidelines and ultrasound.

OBJECTIVES: International guidelines exist for chest drain insertion and recommend identifying the fifth intercostal space or above, around the midaxillary line. In a recent study, applying these guidelines in cadavers risked insertion in the 6th intercostal space or below in 80% of cases. However, there are limitations of cadaveric studies and this investigation uses ultrasound to determine the intercostal space identified when applying these guidelines in healthy adult volunteers. METHODS: On each side of the chest wall in 31 volunteers, the position for drain insertion was identified using the European Trauma Course method, Advanced Trauma Life Support (ATLS) method, British Thoracic Society's 'safe triangle' and the 'traditional' method of palpation. Ultrasound imaging was used to determine the relationship of the skin marks with the underlying intercostal spaces. RESULTS: Five methods were assessed on 60 sides. In contrast to the cadaveric study, 94% of skin marks lay over a safe intercostal space. However, the range of intercostal spaces found spanned the second to the seventh space. In 44% of women, the inferior boundary of the 'safe triangle' and the ATLS guidelines located the sixth intercostal space or below. CONCLUSIONS: Current guidelines often identify a safe site for chest drain insertion, although the same site is not reproducibly found. In addition, women appear to be at risk of subdiaphragmatic drain insertion when the nipple is used to identify the fifth intercostal space. Real-time ultrasonography can be used to confirm the intercostal space during this procedure, although a safe guideline is still needed for circumstances in which ultrasound is not possible.

Tidal Heating of Earth-like Exoplanets around M Stars: Thermal, Magnetic, and Orbital Evolutions.

The internal thermal and magnetic evolution of rocky exoplanets is critical to their habitability. We focus on the thermal-orbital evolution of Earth-mass planets around low-mass M stars whose radiative habitable zone overlaps with the "tidal zone," where tidal dissipation is expected to be a significant heat source in the interior. We develop a thermal-orbital evolution model calibrated to Earth that couples tidal dissipation, with a temperature-dependent Maxwell rheology, to orbital circularization and migration. We illustrate thermal-orbital steady states where surface heat flow is balanced by tidal dissipation and cooling can be stalled for billions of years until circularization occurs. Orbital energy dissipated as tidal heat in the interior drives both inward migration and circularization, with a circularization time that is inversely proportional to the dissipation rate. We identify a peak in the internal dissipation rate as the mantle passes through a viscoelastic state at mantle temperatures near 1800 K. Planets orbiting a 0.1 solar-mass star within 0.07 AU circularize before 10 Gyr, independent of initial eccentricity. Once circular, these planets cool monotonically and maintain dynamos similar to that of Earth. Planets forced into eccentric orbits can experience a super-cooling of the core and rapid core solidification, inhibiting dynamo action for planets in the habitable zone. We find that tidal heating is insignificant in the habitable zone around 0.45 (or larger) solar-mass stars because tidal dissipation is a stronger function of orbital distance than stellar mass, and the habitable zone is farther from larger stars. Suppression of the planetary magnetic field exposes the atmosphere to stellar wind erosion and the surface to harmful radiation. In addition to weak magnetic fields, massive melt eruption rates and prolonged magma oceans may render eccentric planets in the habitable zone of low-mass stars inhospitable for life.

Guidelines for chest drain insertion may not prevent damage to abdominal viscera.

OBJECTIVES: Guidelines to improve the ease and safety of chest drain insertion recommend using the fifth intercostal space, around the midaxillary line (MAL). This study aimed to assess whether compliance with published guidelines reliably ensured such placement and avoided the potentially serious complications of subdiaphragmatic insertion and peripheral nerve injury. METHODS: Three international guidelines were assessed by identifying the intercostal space for chest drain insertion using 16 cadavers (32 sides) at a point 1 cm anterior to MAL. The European Trauma Course method was compared with the British Thoracic Society's 'safe triangle' and the ATLS course technique. RESULTS: The level most commonly found was the sixth intercostal space (43%; 41 of 96 sides). Overall the sixth space or below was found in 83% of insertions (80 of 96 sides). In the fifth intercostal space, the long thoracic nerve ran posterior to the marker placed in all cases and the lateral cutaneous branches of intercostal nerves arose anteriorly to the marker in all but one case. CONCLUSIONS: The results suggest these guidelines may result in insertion of chest drains below the fifth intercostal space, potentially risking injury to subdiaphragmatic structures. Peripheral nerves of the lateral thoracic wall appear safe from incisions 1 cm anterior to MAL.

Defining a positive circumferential resection margin in oesophageal cancer and its implications for adjuvant treatment.

BACKGROUND: A positive circumferential resection margin (CRM) has been associated with a poorer prognosis in oesophageal and oesophagogastric junctional (OGJ) cancer. The College of American Pathologists defines the CRM as positive if tumour cells are present at the margin, whereas the Royal College of Pathologists also include tumour cells within 1 mm of this margin. The relevance of these differences is not clear and no study has investigated the impact of adjuvant therapy. The aim was to identify the optimal definition of an involved CRM in patients undergoing resection for oesophageal or OGJ cancer, and to determine whether adjuvant radiotherapy improved survival in patients with an involved CRM. METHODS: This was a single-centre retrospective study of patients who had undergone attempted curative resection for a pathological T3 oesophageal or OGJ cancer. Clinicopathological variables and distance from the tumour to the CRM, measured to ± 0.1 mm, were correlated with survival. RESULTS: A total of 226 patients were included. Sex (P = 0·018), tumour differentiation (P = 0·019), lymph node status (P < 0·001), number of positive nodes (P < 0·001), and CRM distance (P = 0·042) were independently predictive of prognosis. No significant survival difference was observed between positive CRM 0-mm and 0·1-0·9-mm groups after controlling for other prognostic variables. Both groups had poorer survival than matched patients with a CRM at least 1 mm clear of tumour cells. Among patients with a positive CRM of less than 1 mm, those undergoing observation alone had a median survival of 18·6 months, whereas survival was a median of 10 months longer in patients undergoing adjuvant radiotherapy, but otherwise matched for prognostic variables (P = 0·009). CONCLUSION: A positive CRM of 1 mm or less should be regarded as involved. Adjuvant radiotherapy confers a significant survival benefit in selected patients with an involved CRM.

Testing the validity of the ATLS classification of hypovolaemic shock.

AIM: The Advanced Trauma Life Support system classifies the severity of shock. The aim of this study is to test the validity of this classification. METHODS: Admission physiology, injury and outcome variables from adult injured patients presenting to hospitals in England and Wales between 1989 and 2007 and stored on the Trauma Audit and Research Network (TARN) database, were studied. Patients were divided into groups representing the four ATLS classes of shock, based on heart rate (HR) systolic blood pressure (SBP), respiratory rate (RR) and Glasgow Coma Score (GCS). The relationships between variables were examined by classifying the cohort by each recorded variable in turn and deriving the median and interquartile range (IQR) of the remaining three variables. Patients with penetrating trauma and major injuries were examined in sub-group analyses. RESULTS: In blunt trauma patients grouped by HR, the median SBP decreased from 128 mmHg in patients with HR<100 BPM to 114 mmHg in those with HR>140 BPM. The median RR increased from 18 to 22 bpm and the GCS reduced from 15 to 14. The median HR in hypotensive patients was 88 BPM compared to 83 BPM in normotensive patients and the RR was the same. When grouped by RR, the HR increased with increasing RR but there were no changes in SBP. CONCLUSION: In trauma patients there is an inter-relationship between derangements of HR, SBP, RR and GCS but not to the same degree as that suggested by the ATLS classification of shock.

Content prioritisation of the College of Emergency Medicine specialty curriculum: an exploratory study using a modified Delphi approach.

AIMS: To determine opinion in relation to prioritisation of topics within the clinical curriculum of the College of Emergency Medicine. METHODS: A modified iterated Delphi technique was used employing a participant panel of 40 randomly selected consultants in emergency medicine. Free text was used in order to generate issues for opinion. Likert scales were then employed to refine this opinion. RESULTS: The overall response rate was 50%. Group opinion favoured curricular prioritisation based on a range of clinical indicators. Applying a prioritisation based on exit examination content was not supported. CONCLUSION: Application of a consensus methodology incorporating free text and Likert scales allows expert opinion to be generated in relation to curricular prioritisation. This helps shape the format and educational utility of the specialty curriculum.

Designing tailored biomaterial surfaces to direct keratinocyte morphology, attachment, and differentiation.

Precisely engineering the surface chemistry of biomaterials to modulate the adsorption and functionality of biochemical signaling molecules that direct cellular functions is critical in the development of tissue engineered scaffolds. Specifically, this study describes the use of functionalized self-assembled monolayers (SAMs) as a model system to assess the effects of biomaterial surface properties on controlling fibronectin (FN) conformation and concentration as well as keratinocyte function. By systematically analyzing FN adsorption at low and saturated surface densities, we distinguished between SAM-dependent effects of FN concentration and conformation on presenting cellular binding domains that direct cellular functions. Quantitative image analyses of immunostained samples showed that modulating the availability of the FN synergy site directly correlated with changes in keratinocyte attachment, spreading, and differentiation, through integrin-mediated signaling mechanisms. The results of this study will be used to elucidate design features that can be incorporated into dermal equivalents and percutaneous implants to enhance the rate of re-epithelialization and tissue regeneration. Furthermore, these findings indicate that SAM-based model systems are a valuable tool for designing and investigating the development of scaffolds that regulate the conformation of extracellular matrix cues and cellular functions that accelerate the rate of tissue regeneration.

The advanced life support group's view of HOSPEX.

This paper explores some of the principles and intentions behind simulation in medical education and explores the extent to which HOSPEX fits within an accepted design. It further points to the direction that HOSPEX will need to take in order to maximise its capacity to aid the delivery of exemplary patient safety.

Glutathione supplementation to University of Wisconsin solution causes endothelial dysfunction.

INTRODUCTION: Glutathione (GSH) is added to University of Wisconsin (UW) organ preservation solution to protect against oxidative stress. This study assesses the effect of GSH-supplementation on endothelial function in tissues subjected to cold ischaemia and compares its effects to a mono-ethyl ester equivalent (GSH-MEE) and S-nitrosated GSH (GSNO). METHODS: Rat aortic rings were stored for 1 h or 48 h in cold, hypoxic UW solution with or without GSH (3 mM), GSH-MEE (3 mM) or GSNO (100 mciroM) supplementation. Aortic rings were reoxygenated in warm Krebs solution; smooth muscle function was assessed by responses to phenylephrine (PE), and endothelial function by vasodilatation to the endothelium-dependent dilator, acetylcholine (ACh). The protective effects against oxidant-induced endothelial cell death were assessed in cultured human umbilical vein endothelial cells (HUVEC). RESULTS: Supplementation of UW with either GSH or GSH-MEE had no effect on vascular responses to PE, but smooth muscle contraction was significantly attenuated in rings incubated for 48 h with GSNO. Endothelium-dependent relaxation was significantly impaired in tissues stored under hypoxic conditions in GSH, GSH-MEE and GSNO supplemented UW solution for 1 h. However, impairment at 48 h was significantly more pronounced in GSH-treated vessels. Cultured HUVEC death was exacerbated by GSH and GSH-MEE in unstressed cells and in those stressed with a superoxide anion generator. CONCLUSIONS: GSH supplementation of UW solution exacerbates cold-ischaemia induced endothelial dysfunction. GSNO did not share the detrimental effects of GSH and promoted NO-mediated vasodilatation.

Risk factors for methadone outside treatment programs: implications for HIV treatment among injection drug users.

BACKGROUND: Diversion of methadone outside treatment programs occurs, yet reasons for use of 'street methadone' are characterized poorly. Self-medication for withdrawal symptoms is one plausible hypothesis. Among HIV-infected drug users, some antiretroviral medications can reduce potency of methadone, yet any association between such effects and the use of supplemental methadone sources remains undetermined. OBJECTIVE: To estimate the frequency and risk factors for use of street methadone. METHODS: Injection drug users (IDUs) recruited through extensive community outreach in 1988-89 and 1994 were followed semi-annually with questionnaires about health history, use of licit and illicit drugs including methadone and HIV-related assays. Analyses were performed using generalized estimating equation logistic regression. RESULTS: Of 2811 IDUs enrolled and eligible for analysis, 493 people reported use of street methadone over 12 316 person-years of follow-up (4.0/100 person-years). In multivariate analyses, street methadone use was more common among women, whites, those 40-59 years old, those who reported withdrawal symptoms, past methadone program attendance (6-12 months before visit), recent heroin injection with or without cocaine (but not cocaine alone), smoking or sniffing heroin and reported trading sex. Street methadone was not associated with HIV infection or treatment. CONCLUSION: The results suggest that older IDUs still using heroin may be using street methadone to treat signs of withdrawal. The absence of a higher rate of street methadone use in HIV seropositive IDUs reveals that antiretroviral/methadone interactions are not a primary determinant of use outside of treatment settings.

Exposure or expert? Setting standards for postgraduate education through a Delphi technique.

OBJECTIVES: The aim of this study was to determine if a syllabus of upper limb anatomy for emergency clinicians composed by an expert panel reflected clinical practice as experienced by those at whom the syllabus would be directed. METHODS: A three round Delphi study was performed using an expert group. We compared this with a measure of the exposure to anatomical concepts in the day to day practice of trainees in emergency medicine. RESULTS: In total, 404 separate anatomical facts relating to the upper limb were reviewed by both groups. There was poor agreement (kappa = 0.348) between the expert group and the trainees. CONCLUSION: We have shown disparity between what an expert group believes trainees should know and what trainees are actually exposed to in clinical practice. We believe this demonstrates that curriculum development must strike a balance between important (expert) and common (exposure) information. We have shown how an expert:exposure matrix may be used to inform curriculum development.

Determination of required anatomical knowledge for clinical practice in emergency medicine: national curriculum planning using a modified Delphi technique.

OBJECTIVES: To identify the content of the postgraduate anatomy curriculum for trainees in emergency medicine (EM) in the UK. METHODS: Modified Delphi technique involving 160 randomly sampled consultants in EM. The outcome measure was percentage agreement, based upon a three round iterated Delphi process, of participants to items derived from a standard anatomy text being core knowledge for postgraduate clinical practice in the specialty. A national curriculum document was derived as a result of the data obtained. RESULTS: Response rates ranged from 61% to 70% after three Delphi rounds. From an initial overall questionnaire content of 808 discrete items, 64% was retained as core required knowledge following iteration. This formed the basis of a national consensus anatomy curriculum both to inform question development in postgraduate EM examinations and to benchmark anatomical knowledge requirements for safe clinical practice. CONCLUSIONS: Application of a national consensus methodology allows for determination of curricular content in anatomy. The principles can be applied to all aspects of training and curricular policy at national collegiate level to guide the development of robust documentation.

Factors associated with interest in initiating treatment for hepatitis C Virus (HCV) infection among young HCV-infected injection drug users.

OBJECTIVE: We sought to identify factors associated with interest in receiving therapy for hepatitis C virus (HCV) infection among HCV-infected injection drug users (IDUs) in 3 United States cities. METHODS: IDUs aged 18-35 years who were HCV-infected and seronegative for human immunodeficiency virus underwent surveys on behaviors, experience, and interest in treatment for HCV infection and readiness to quit drug use. RESULTS: Among treatment-naive IDUs (n=216), 81.5% were interested in treatment for HCV infection, but only 27.3% had seen a health-care provider since receiving a diagnosis of HCV infection. Interest in treatment for HCV infection was greater among IDUs with a high perceived threat of progressive liver disease, those with a usual source of care, those without evidence of alcohol dependence, and those with higher readiness scores for quitting drug use. Interest in treatment for HCV infection was 7-fold higher among IDUs who were told by their health-care provider that they were at risk for cirrhosis or liver cancer. CONCLUSIONS: Improving provider-patient communication and integrating treatments for substance abuse and HCV may increase the proportion of IDUs who initiate treatment for HCV infection.